Next President Must Change Course on PEPFAR

India does not make the list of the fifteen focus countries targeted by the President’s Emergency Plan for
AIDS Relief (PEPFAR), with Vietnam
being the only representative from the continent. And yet the traditional
make-up of the country, the emphasis on cultural mores and rituals and
the contesting contexts and sub-contexts within the country, could easily act as an example for many parts of the world.

Here, like in many other countries, change is welcome as long as it does not disturb the
traditional set-up of communities. Dislodging
cultural practices, many of which might be gender imbalanced, continues
to meet with opposition in the pursuit of preservation of this cultural
ethos. And marriage is at the heart of most of the traditions guiding
Indian society. A good marriage is where the woman redeems herself and
a bad marriage is a curse she brings upon herself.

Therein lies the problem with the prostitution pledge PEPFAR grantees are obligated to sign. Fathers of girl(s),
even today, in many parts of the country carry the "burden" of the
girl until the time he finds a suitable groom only to shift that burden
on to him. Hence, one of the easiest and oldest ways of luring unsuspecting
girls and women into the sex trade is the promise of matrimony. Brought
up amidst strong representations of virtue and honor, these are women
who even when rescued from the labyrinthine network of the industry
hesitate to return to their communities for fear of ostracism or the "shame" that they bring to the family. Thus, they are often compelled
to return to the very life they long fight to leave. So are these young
lives condemned to a life of stigma and discrimination and to be deprived
of medical care and attention simply because they reconciled to sex
work as their only means of survival. In a society where these women
suffer a near pariah status the availability or non-availability of
aid hinged on the prostitution pledge, in effect, is institutionalizing
their vulnerability by covertly stating that these women do not deserve
care and support because of the work they do.

Given the prevalence of HIV
among sex workers, migrant workers, and the wives migrant workers return to, groups working within these communities are bound to find the prostitution pledge
a major hindrance while attempting to provide legal, social and health
services or in aiding in whatever way possible these sex workers. The prostitution pledge undermines the very
programs that so far have proved the most successful in reversing
the spread of the virus. It in effect excludes from its group of beneficiaries
a substantial portion of the high risk populations in the country and
also keeps out groups that do not fit into the high risk category.

So while a sex worker is denied care
because the mode of transmission (sex work), the man transmits HIV to his spouse or to other partners due to decreased funding for condom provision or the lack of ability among sex workers to negotiate
for condom use. What the "most-at-risk" group clause in PEPFAR does, then, is to keep HIV education, counseling and care out of the reach
of these women who contract it from their husbands — since they are not
considered within the vortex of these high risk groups.

Married women form a substantial component
of the HIV infected population mainly because of early marriages to
much older and often already sexually active men. In the absence of
information on the subject — since sex itself is a taboo subject —
they very rarely are equipped to protect themselves from infections.
Pregnancy is the entry point to discuss other issues like reproductive
and sexual health, HIV/AIDS and even abortion.

This is significant in many cultural contexts in which contraception is socially and morally criminalized, leaving women
with very few options of birth control. While a miniscule minority might
be able to exercise their choice of timing the pregnancies and the use
of contraceptives, by and large this choice is not available to most.
For a long time midwives are the closest pregnant women have come to any kind
of structured health care during and after their childbirths. In the
absence of access to information on family planning, it is very often
midwives who also act as the carriers of information on various issues
like contraception and HIV. Public health experts in countries like
India and even the Indian government recognized the role of family planning
providers in also disseminating HIV prevention education and services,
including testing, allowing this information to reach more people at
risk of HIV.

What are the implications of
the global gag rule (GGR) here? The
GGR in effect is snatching from women their only access to information
and help on the subject, especially since these family planning workers
are often better positioned to prevent new infections among women and
youth – also the more vulnerable groups.

The problem with clauses
such as the global gag rule and prostitution pledge is that they give little
maneuvering space to groups and organizations implementing the programs. These groups and organizations must ensure that the aid reaches those most in need yet, ironically, the aid ties the programs down by their embedded conditionalities, ultimately making
them ineffective as they reach the least number in more time instead
of the most in the least time.

The fight against the virus is not
simply a matter of a successful morality lecture. Whom are we attempting
to impact ultimately? All those who require this care or simply those
who have made "morally correct" choices? Sustainable
development in countries like India is hinged on family planning policies
and a rights-based approach to HIV/AIDS. Can the implementation of any
program towards controlling the virus be guided by a set of "dos
and don’ts" or of disciplining certain groups (by denying them
aid) for not leading a moral life, according to some?

A more significant danger of bills
like PEPFAR is that they do find support amidst the more conservative
pressure groups and policy planners in the country. So the focus could
very easily be shifted from universal access to medical care, to practices similar to abstinence only, the prostitution pledge or abortion
relegating more controversial measures
to the background. The $50 billion effort of PEPFAR should ensure wider
information and access to HIV/AIDS treatment as the immediate need and
any denial of either funds or treatment to certain groups
is an infringement on basic human rights.

There are critical choices that the
new government has to make; choices that might reverse not just trends
in the developing world with relation to maternal health but also as
a consequence impact the health of the families they form, the communities
they inhabit and the society they build.